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Mary Talley Dorn, M.D. Norman R. Friedman, M.D.
• • • • • Celsus 50 A.D. Caque of Rheims Philip Syng Wilhelm Meyer 1867 Samuel Crowe
• 8 weeks: Tonsillar fossa and palatine tonsils develop from the dorsal wing of the 1st pharyngeal pouch and the ventral wing of the 2nd pouch; tonsillar pillars originate from 2nd/3rd arches • Crypts 3-6 months; capsule 5th month; germinal centers after birth • 16 weeks: Adenoids develop as a subepithelial infiltration of lymphocytes
• Plica triangularis • Gerlach’s tonsil
• Fossa of Rosenmüller • Passavant’s ridge
• Ascending and descending palatine arteries • Tonsillar artery • 1% aberrant ICA just deep to superior constrictor
• Ascending pharyngeal, sphenopalatine arteries
Histology Tonsils • • • • Specialized squamous Extrafollicular Mantle zone Germinal center Adenoids • Ciliated pseudostratified columnar • Stratified squamous • Transitional .
Common Diseases of the Tonsils and Adenoids • Acute adenoiditis/tonsillitis • Recurrent/chronic adenoiditis/tonsillitis • Obstructive hyperplasia • Malignancy .
Acute Adenotonsillitis Etiology • 5-30% bacterial. of these 39% are beta-lactamaseproducing (BLPO) • Anaerobic BLPO GABHS most important pathogen because of potential sequelae • Throat culture • Treatment .
Microbiology of Adenotonsillitis Most common organisms cultured from patients with chronic tonsillar disease (recurrent/chronic infection.influenza • S. aureus • Streptococcus pneumoniae Tonsil weight is directly proportional to bacterial load. . hyperplasia): • Streptococcus pyogenes (Group A beta-hemolytic streptococcus) • H.
carcinoma Diptheria Scarlet fever Agranulocytosis .Acute Adenotonsillitis Differential diagnosis Infectious mononucleosis Malignancy: lymphoma. leukemia.
steroids. antibiotics directed against BLPO and anaerobes for 3-6 weeks will eliminate need for surgery in 17% .Medical Management • PCN is first line. IV abx. even if throat culture is negative for GABHS • For acute UAO: NP airway. and immediate tonsillectomy for poor response • Recurrent tonsillitis: PCN injection if concerned about noncompliance or antibiotics aimed against BLPO and anaerobes • For chronic tonsillitis or obstruction.
Obstructive Hyperplasia • Adenotonsillar hypertrophy most common cause of SDB in children • Diagnosis • Indications for polysomnography • Interpretation of polysomnography • Perioperative considerations .
Unilateral Tonsillar Enlargement Apparent enlargement vs true enlargement Non-neoplastic: • Acute infective • Chronic infective • Hypertrophy • Congenital Neoplastic .
Peritonsillar Abscess .
ICA Aneurysm .
Pleomorphic Adenoma .
Other Tonsillar Pathology • Hyperkeratosis. mycosis leptothrica • Tonsilloliths .
Retention Cysts .
Supratonsillar Cleft .
Indications for Tonsillectomy. Historical Evolution .
3. positive culture for GABHS. tonsillar/pharyngeal exudate. cervical LAD (>2cm) or tender LAD.Indications for Tonsillectomy Paradise study • Frequency criteria: 7 episodes in 1 year or 5 episodes/year for 2 years or 3 episodes/year for 3 years • Clinical features (one or more): T 38. antibiotic treatment .
Indications for Tonsillectomy AAO-HNS: • • • • • • 3 or more episodes/year Hypertrophy causing malocclusion. suspicious for malignancy Individual considerations . UAO PTA unresponsive to nonsurgical mgmt Halitosis. not responsive to medical therapy UTE.
Indications for Adenoidectomy Paradise study (1984) • 28-35% fewer acute episodes of OM with adenoidectomy in kids with previous tube placement • Adenoidectomy or T & A not indicated in children with recurrent OM who had not undergone previous tube placement Gates et al (1994) • Recommend adenoidectomy with M & T as the initial surgical treatment for children with MEE > 90 days and CHL > 20 dB .
Indications for Adenoidectomy Obstruction: • • • • • Chronic nasal obstruction or obligate mouth breathing OSA with FTT. cor pulmonale Dysphagia Speech problems Severe orofacial/dental abnormalities Infection: • Recurrent/chronic adenoiditis (3 or more episodes/year) • Recurrent/chronic OME (+/.previous BMT) .
and mouth breathing • Rhinorrhea. post nasal drip • “Adenoid facies” • “Milkman” & “Micky Mouse” • Overbite. nocturnal cough. snoring.PreOp Evaluation of Adenoid Disease • Triad of hyponasality. long face. crowded incisors .
treat adenoids first .PreOp Evaluation of Adenoid Disease Differential diagnoses • • • • Allergic rhinitis Sinusitis GERD For concomitant sinus disease.
bifid uvula • CNS or neuromuscular disease • Preexisting speech disorder? .PreOp Evaluation of Adenoid Disease Evaluate palate • Symptoms/FH of CP or VPI • Midline diastasis of muscles.
Accuracy of lateral neck films is dependent on proper positioning and patient cooperation.PreOp Evaluation of Adenoid Disease Lateral neck films are useful only when history and physical exam are not in agreement. .
PreOp Evaluation of Adenoid Disease .
PreOp Evaluation of Tonsillar Disease History • • • • • Documentation of episodes by physician FTT Cor pulmonale Poststreptococcal GN Rheumatic fever .
PreOp Evaluation of Tonsillar Disease TONSIL SIZE • 0 in fossa • +1 <25% occupation of oropharynx • +2 25-50% • +3 50-75% • +4 >75% Avoid gagging the patient .
PE • If unstable. need neurosurgical evaluation preoperatively • Large tongue and small mandible… difficult intubation • Prone to cardiac arrhythmias/hypotension during induction .PreOp Evaluation of Tonsillar Disease Down syndrome • 10% have AA laxity • Obtain lateral cervical films (flexion/extension) when positive findings on history.
PreOp Evaluation for Adenotonsillar Disease Coagulation disorders • • • • • • Historical screening CBC. PT/PTT. BT. vWF activity Hematology consult von Willebrand’s disease ITP Sickle cell anemia .
KTP) … Surgeon’s preference .Principles of Surgical Management Numerous techniques: • • • • Guillotine Tonsillotome Beck’s snare Dissection with snare (Scissor dissection. Fisher’s knife dissection. Finger dissection • Electrodissection • Laser dissection (CO2.
hemorrhage Age < 3 Home > 45 minutes away Poor socioeconomic condition Comorbid medical problems Surgery for OSA or PTA Abnormal coagulation values (+/.Post Operative Managment Criteria for Overnight Observation • • • • • • • Poor oral intake. vomiting.identified disorder) in patient or family member .
Complications #1 Postoperative bleeding Other: • • • • Sore throat. uvular swelling Respiratory compromise Dehydration Burns and iatrogenic trauma . otalgia.
Rare Complications • • • • • • • Velopharyngeal Insufficiency Nasopharyngeal stenosis Atlantoaxial subluxation/ Grisel’s syndrome Regrowth Eustachian tube injury Depression Laceration of ICA/ pseudoaneursym of ICA .
Management of Hemorrhage • • • • • Ice water gargle. afrin Overnight observation and IV fluids Dangerous induction ECA ligation Arteriography .
” • You call her pediatrician… he is out of town and his nurse can’t find the chart .Case study • 13 year old female referred by PCP for frequent throat infections • “She’s always sick. She’s been on four different antibiotics this year.
. no prior surgical procedures • Takes motrin for menustrual cramps • No personal history of bleeding other than occasional nose bleeds and extremely heavy periods. • Family history unknown.Case study • No known medical problems. Patient is adopted.
If she misses any more school.” • You hesitate. She adds.” . “I had to go on welfare because I’ve missed so much work from her being out sick. • Mom breaks down in tears when you tell her you do not have enough documentation of illness to warrant T & A. “Her grades have dropped from all A’s to all F’s.Case study • Physical exam is unremarkable. she’ll be held back.
BT.Case study • You confirm with her pediatrician that she has had 4 episodes of tonsillitis this year and agree to T & A. • She has a mild microcytic anemia and prolonged bleeding time. • You order vWF activity level and consult hematology . PTT. you order a PT. • Because of her history of epistaxis and menorrhagia. CBC.
• Before surgery.Case study • She has a subnormal level of vWF. she receives desmopressin 0. • You advise her to stop taking motrin.3 microg/kg IV over 30 min and amicar 200mg/kg. . which responds to a DDAVP challenge (rise in vWF and Factor VII greater than 100%).
Case study • She receives the same dose of DDVAP 12 hours postoperatively and every morning. • Before each dose of DDAVP. serum sodium is drawn. . • Amicar is given 100mg/kg PO q 6 hr. Sodium levels drop to 130. • Desmopressin is discontinued and substituted with cryoprecipitate.
9 to 9. • You order cryoprecipitate. • Hemoglobin has dropped from 11. draw a Factor VII level and CBC.6. .Case study • Patient presents to the ER on POD # 7 complaining of intermittent bleeding from her mouth. and call her hematologist.
admit the patient for overnight observation. an old clot is present • You establish IV access.Case study • PE reveals no active bleeding. have her gargle with ice water. patient is discharged the next day . and administer crypoprecipitate • No further bleeding occurs.
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